Niamh Doyle and Marie Tierney
Perinatal Mental Health
Perinatal mental health has been recognised globally as a critical public health concern1. Untreated maternal mental health in pregnancy and in the years following birth can have detrimental consequences for not only the mother’s health2, but also for pregnancy outcomes3, marital relationships4, paternal mental health5 and the social, emotional and cognitive development of the growing infant3,6-11. Given that the antenatal period and first three years of life are critical for brain development, the neural connections made during this time form the foundation for good emotional health and attachment12-14.
Mental health difficulties are common among women in pregnancy and in the postnatal period, with a 12-13% prevalence rate of depression and anxiety during pregnancy and 15-20% of women experiencing significant distress in the first year after childbirth15. In Ireland, between 2013 and 2015, four out of seven maternal deaths reported were due to suicide, making suicide the leading cause of direct maternal death occurring between six weeks and one year after pregnancy16. This corresponds to figures from the UK and other high-income countries2,17.
Worldwide, the importance of perinatal mental health has been recognised through the World Health Organisation Millennium Development Goals, post-2015 millennium development goals, and national strategy documents in Australia12, the UK15 and the United States18. Overall, guidelines have emphasised the importance of timely intervention and specialist services for perinatal mental health15,19-21. NICE15 guidelines for example, have stated that women with a known or suspected mental health problem in pregnancy or the postnatal period should be assessed for treatment within two weeks of referral and psychological interventions should be offered within one month of initial assessment.
Perinatal Mental Health Services in Ireland
In the Republic of Ireland, the government has committed to enhancing maternal ante-natal and early childhood development services and strengthening pre-natal and ante-natal supports around the mother22-23. The Health Service Executive Mental Health Division Operational Plan 201724 outlined a plan to develop specialist perinatal services in Cork University and Limerick Hospitals. At the time of this audit, there were no dedicated perinatal or infant mental health services in the Republic of Ireland25. Moreover, outside of the large Dublin hospitals, there were no dedicated perinatal mental health staff and no perinatal psychology positions26. Most women with perinatal mental health difficulties in Ireland therefore receive fragmented care between maternity, general practice and mental health services, and many women have reported an emphasis on physical and biological aspects of pregnancy, to the exclusion of mental and emotional well-being26-27. Since this audit was completed, the Health Service Executive have launched a new Model of Care for Specialist Perinatal Mental Health in Ireland28.
Adult Mental Health Teams
It has been acknowledged that women in the perinatal period are likely currently accessing psychological services within adult mental health teams29. Until specialist perinatal mental health services are achieved in Ireland, adult mental health teams have a responsibility to heed decades of research supporting the need for early intervention in this cohort of women. Psychology services have an opportunity to intervene quickly and effectively to treat the mental health needs of mothers, which may have a secondary gain of improving outcomes for pregnancy and the growing infant. Indeed, the Psychological Society of Ireland have identified psychologists as having a pivotal role to play in providing specific perinatal and infant mental health services, which involves assessment of the parent-child relationship, promotes mother and infant wellbeing and includes psychotherapeutic intervention for mothers’ mental health needs.
Aims of the Current Study
In order to plan intervention and resource allocation for perinatal mental health, it is important to determine the number of women presenting to adult mental health psychology services and audit the current waiting times for this group of women. This study aimed to examine the referral patterns in five Adult Mental Health Psychology services of pregnant women and women with infants from under three years of age. It was expected that gaps in service provision would be identified, with implications for developing timely and appropriate services for pregnant women and mothers with young infants.
Definitions used in this study
Perinatal Mental Health is defined in this study as woman’s mental health during pregnancy and throughout the first three years after birth.
This audit focused on perinatal women referred to five adult mental health psychology services between January 2013 and December 2016. Data was collected through chart reviews of psychology and multi-disciplinary (MDT) files in five secondary care services in the South of Ireland. Information collected included demographic information, referral patterns (year of referral, source of referral, waiting time between referral and first appointment with psychology, presenting difficulties) and psychological intervention delivered.
Ethical approval was obtained from University College Cork Ethics Committee on 18th April 2017.
In total, 26 women were referred to psychology services from 2013 to 2016, with an average of 6.5 referrals each year (see Table 1 for service user characteristics). One individual was both pregnant and with an infant under three years. The mean age was 32.27 (range 22-43).
Table 1: Service User Characteristics
Table 2 shows the referral patterns of service users, including number of women referred each year, presenting difficulties, the source of referral and wait times from referral to first appointment with psychology.
Table 2: Referral Patterns of Service Users
Three women were removed from waiting lists prior to psychological assessment: one client sought private psychological help due to the long waiting lists; one moved region and a final woman was referred to another member of the multi-disciplinary team due to the long waiting list for psychology. Twenty-three service users had an initial appointment with psychology services. The average waiting time of these service users from referral to initial appointment was 35.52 weeks (range 1 – 103). One quarter of individuals were seen within two weeks, while over half (52%) of service users remained on the waiting list for 34 weeks or longer.
Eighteen individuals were offered a psychological intervention and information about the psychological model used was available for 16 of these clients. See Table 3 for frequencies of interventions delivered. Eleven individuals received an integrative psychological intervention, with a number of the models listed in Table 3.
Table 3: Frequencies of Psychological Intervention Delivered
The present audit explored referral patterns of pregnant women and women with infants under three years of age, referred to psychology in five adult mental health teams in Ireland between 2013 and 2016.
Number of referrals.
As expected29, pregnant and postnatal women presented to psychology services in five adult mental health teams in Ireland. This was limited to approximately 1.3 referrals to each service each year. In the absence of specialised perinatal mental health services and the small number of women presenting to adult psychology services, it may be feasible to offer priority to this group without overwhelming services. As no data was collected on overall referral rates to individual services, the proportion of these to total referrals is unknown.
Considering the finding that perinatal status was not routinely recorded on referral information, this audit may underrepresent the number of women in the perinatal period presenting to adult psychology services. The relatively low referral rate may also be due in part to women obtaining care from alternative professionals on adult mental health teams such as psychiatry or nurse therapy; voluntary organisations such as Aware or care from their General Practitioner. It is also likely that many women receive no care for their mental health during this time, due to factors such as a lack of access to services, stigma and shame preventing women from disclosing difficulties and negative previous experiences of disclosure to mental health professionals30.
Anxiety and depression were the most common mental health difficulties for perinatal women, aligning with international data15. There may be scope for developing group-based interventions for these problems, with a focus on prevention and promotion of early intervention for existing perinatal and infant mental health problems.
Despite worldwide recognition of the importance of timely intervention for perinatal maternal mental health, over half of individuals in this study remained on the waiting list for 34 weeks or longer. Additionally, one individual was taken off the waiting list for psychology and offered an alternative intervention due to long waiting times. These findings represent a significant discrepancy between the services that women are receiving in adult mental health teams, and international recommendations that give priority to early intervention15.
Until specialist perinatal mental health services are established in Ireland, adult mental health teams need to alter their service provision to ensure that all perinatal women have timely access to their psychology services. It is recommended that this group of women are fast-tracked for services and provided with intervention within one month of referral, in accordance with NICE15 guidelines. Additionally, waiting times from referral to initial appointment should be routinely monitored.
Perinatal women in psychology services received integrated psychological interventions, using models from cognitive behavioural therapy, mindfulness and compassion focused therapy. These interventions, when specifically adapted for the needs of perinatal women have been associated with overall improvements in mental health31.
Lack of routinely collected data
This audit highlighted a lack of routinely collected data on women in the perinatal period in adult mental health teams. Documentation of pregnancy or maternal status was recorded in a fragmented and ad hoc manner. Given the importance of early intervention, it is recommended that data is routinely collected on waiting times for women who are pregnant or with infants under three years of age, so that this group can be provided with prioritised access to psychology services, in according with NICE15 guidelines.
Strengths & Limitations
Small sample size. The small sample size of the present audit precluded analysis on factors associated with longer waiting times.
Infant mental health practices. This audit focused on individual psychology interventions with perinatal women. As such, data was not collected on specific infant mental health practices used in existing adult mental health psychology services (e.g. screening techniques for infant mental health; assessment of mother-infant attachment relationship). Recently, the Psychological Society of Ireland have advocated for infant mental health practices to be incorporated into all existing services providing care to parents and families. It has also recommended psychologists in adult mental health teams to acquire appropriate knowledge of early childhood development and an understanding of screening and diagnostic techniques for this age group25,32. These recommendations were made in light of evidence that effective treatment for some perinatal mental health difficulties is not always sufficient to improve the developing infant-mother relationship33. Moreover, it has been previously documented that opportunities to promote infant mental health have traditionally been ignored or minimised within adult services in Ireland32,34-35. Future research could therefore audit the use of screening and diagnostic techniques for infant mental health within adult psychology services.
Focus on women and mothers. Given that women are at a higher risk for depression and anxiety36 this study focused exclusively on pregnant and postnatal women. Evidence suggests however that fathers’ mental health is also associated with child development37,38 and is common across the perinatal period36. Data on pregnancy and infants is not routinely collected by adult mental health services in Ireland, which may make distinguishing men within the perinatal period difficult, or impossible. It is recommended that information is clearly documented about men and women in the perinatal period in adult mental health files.
Untreated maternal mental health in pregnancy and in the years following birth can have detrimental consequences for not only the mother’s health, but also for pregnancy outcomes, paternal health and the social, emotional and cognitive development of the growing infant. With no dedicated perinatal mental health services yet in Ireland, it is recommended that adult mental health services adhere to international guidelines, by providing perinatal women with timely access to effective interventions.
This audit showed that a small number of perinatal women are referred to adult mental health psychology services each year. Data is not routinely collected on this group of women however and many women are left on waiting lists for longer than 34 weeks. Given the importance of early intervention, mental health teams may wish to fast-track this group on psychology waiting lists to ensure they are seen within one month of referral (in accordance with NICE guidelines). The small number referred to services means that this may be feasible, even with limited resources. By intervening early with effective interventions, this will have a positive impact on mothers and their families, and contribute towards a healthy cycle of transgenerational mental health.
Since this audit was completed, the Health Service Executive launched a new Model of Care for Specialist Perinatal Mental Health in Ireland28. It identified six ‘hub’ hospitals in Ireland with the highest number of deliveries within a hospital group. The new model outlines that each hub hospital will have a dedicated specialist perinatal mental health service, consisting of a multidisciplinary team. These teams will be led by a consultant psychiatrist in perinatal psychiatry and include one whole time equivalent senior psychology role. The model also encompasses additional training for individuals working in Primary Care Psychology, such that individuals with milder mental health presentations can access appropriate support within the community.
Summary of Recommendations
The following recommendations are made based on findings from this audit.
- Current pathways of referrals should be audited within adult mental health teams, to ensure that pregnant and postnatal women receive the most appropriate care for their needs.
- It is recommended that psychological services within adult mental health teams prioritise timely interventions for pregnant and postnatal women
- Waiting times should be routinely monitored in line with NICE (2014) guidelines
Where possible, pregnant women and mothers of children under three should be clearly identifiable in mental health records, so that this group can be offered prioritised access to services.
- United Nations. United Nations Millennium Declaration. 55/2. United Nations General Assembly. 2000
- Knight M, Tuffnell D, Kenyon S, Shakespear J, Gray R, & Kurinczuk JJ. on behalf of MBRRACE-UK. Saving lives, improving mothers’ care – surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK And Ireland confidential enquiries into maternal deaths and morbidity 2009-13. Oxford : National Pernatal Epidemiology Unit, University of Oxford. 2015.
- Grigoriadis S, VonderPorten EH, Mamisashvili L, Tomlinson G, Dennis CL, Koren G…. et al. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. Journal of Clinical Psychiatry. 2013; 74(4): 321-341. Doi: 10.4088/JCP.12r07968
- Mamun AA, Clavarino AM, Najman JM, Williams GM, O’Callagha MJ, & Bor W. Maternal depression and the quality of marital relationship: A 14-year prospective study. Journal of women’s health. 2009; 18(12): 2023-2031. Doi: 10.1089/jwh.2008.1050.
- Wee KY, Skouteris H, Pier C, Richardson B, Milgrom J. Correlates of ante-and postnatal depression in fathers: a systematic review. Journal of affective disorders. 2011 May 1;130(3):358-77.
- Pawlby S, Hay DF, Sharp D, Waters CS, & O’Keane V. Antenatal depression predicts depression in adolescent offspring: prospective longitudinal community-based study. Journal of affective disorders. 2009; 113(3): 236-243. Doi: 10.1016/j.jad.2008.05.018.
- O’Donnell K, O’Connor TG, & Glover V. Prenatal stress and neurodevelopment of the child: Focus on the HPA axis and role of the placenta. Developmental Neuroscience. 2009; 31(4): 285-292. Doi: 10.1159/000216539.
- O’Donnell KJ, Glover V, Edgar RD, O’Connor TG. Inter-individual differences in the effects of maternal prenatal anxiety on child neurodevelopment: Implications for personalized medicine in perinatal mental health. Psychoneuroendocrinology. 2016 Sep 1;71:6.
- Koutra K, Chatzi L, Bagkeris M, Vassilaki M, Bitsios P, & Kogevinas M. Antenatal and postnatal maternal mental health as determinants of infant neurodevelopment at 18 months of age in a mother–child cohort (Rhea Study) in Crete, Greece. Social Psychiatry And Psychiatric Epidemiology. 2013; 48(8): 1335-1345. Doi: 10.1007/s00127-012-0636-0
- Kluczniok D, Hindi Attar C, Fydrich T, Fuehrer D, Jaite C, Domes G, & … Bermpohl F. Transgenerational effects of maternal depression on affect recognition in children. Journal Of Affective Disorders. 2016; 189: 233-239. doi:10.1016/j.jad.2015.09.051
- Davis EP, & Sandman CA. The timing of prenatal exposure to maternal cortisol and psychosocial stress is associated with human infant cognitive development. Child Development. 2010; 81(1): 131-148. Doi: 10.1111/j.1467-8624.2009.01385.x
- BeyondBlue. National Action Plan for Perinatal Mental Health 2008-2010: Full Report. BeyondBlue: The National Depression Initiative & Perinatal Mental Health Consortium, Australia. 2008
- Giallo R, Cooklin A, Wade C, D-Esposito F, Nicholson JM . Maternal postnatal mental health and later emotional-behavioural development of children: the mediating role of parenting behaviour. Child: care, health and development. 2014; 40(3), 327-336. Doi: 10.1111/cch.12028.
- Winston R, & Chicot R. The importance of early bonding on the long-term mental health and resilience of children. London Journal of Primary Care (Abingdon). 2016; 8(1), 12-14. Doi: 10.1080/17571472.2015.1133012
- National Institute of Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance. NICE UK. 2014.
- O’Hare MF, Manning E, Corcoran P, & Greene, RA. on behalf of Maternal Death Enquiry Ireland. Confidential Maternal Death Enquiry in Ireland: Report for 2013 – 2015. Cork: MDE Ireland. 2017.
- Oates M. Suicide: the leading cause of maternal death. The British Journal of Psychiatry. 2003; 183(4): 279-281. Doi: 10.1192/bjp.183.4.279
- ZERO TO THREE. Making it Happen: Overcoming Barriers to Providing Infant-Early Childhood Mental Health. National Center for Infants, Toddlers and Families, USA. 2012.
- Joint Commissioning Panel for Mental Health (JCP-MH). Guidance for commissioners of perinatal mental health services. London. 2012.
- Scottish Intercollegiate Guidelines Network. Management of Perinatal Mood Disorders: A National Clinical Guideline. SIGN 2012. Webiste: https://www.guideline.gov/summaries/summary/36811
- Royal college of psychiatrists. Perinatal mental health services: recommendations for the provision of services for childbearing women. Royal College of Psychiatrists. 2001.
- Department of Children & Youth Affairs. ‘Better outcomes brighter futures’: the national policy framework for children & young people 2014-2020. Dublin: Stationary Office. 2014.
- Department of Health. Creating a better future together: National maternity strategy 2016-2026. Dublin: Department of Health. 2016.
- Health Service Executive. Mental Health Division Operational Plan. Dublin: Health Service Executive. 2017.
- Perinatal and Infant Mental Health Special Interest Group. Perinatal and infant mental health: position paper and recommendations. Psychological Society of Ireland (PSI) and Perinatal and Infant Mental Health Special Interest Group (PIMHSIG). 2016.
- Association for improvements in the maternity services – Ireland (AIMS; Ireland). Briefing document: Oireachtas Joint Health Committee. Retrieved from Oireachtas. 2017. Website: http://www.oireachtas.ie/parliament/media/committees/health/presentations/Amended-AIMS-Ireland-Opening-Statement–Submission.pdf
- Higgins A, Tuohy T, Murphy R, & Begley C. Mothers with mental health problems. Contrasting experiences of support within maternity services in the Republic of Ireland. Midwifery. 2016; 36: 28-34. Doi: https://doi.org/10.1016/j.midw.2016.02.023
- Health Service Executive, National Mental Health Division. Specialist Perinatal Mental Health Services: Model of Care for Ireland. 2017. Retrieved from https://www.hse.ie/eng/services/list/4/mental-health-services/specialist-perinatal-mental-health/specialist-perinatal-mental-health-services-model-of-care-2017.pdf
- Lyman DR, Holt W, & Dougherty RH. State case studies of infant and early childhood mental health systems: strategies for change. DMA Health Strategies. 2010.
- Moore D, Ayers S, & Drey N. A Thematic Analysis of Stigma and Disclosure for Perinatal Depression on an Online Forum. JMIR Mental Health. 2016; 3(2): 18. Doi: 10.2196/mental.5611
- Lavender TJ, Ebert L, Jones D. An evaluation of perinatal mental health interventions: an integrated literature review. Women and birth: journal of the Australian College of Midwives. 2016; 29(5): 399-406. Doi: 10.1016/j.wombi.2016.04.004
- Nelson F, & Mann T. Opportunities in Public Policy to Support Infant and Early Childhood Mental Health: The Role of Psychologists and Policymakers. American Psychologist. 2011; 66(2): 129 – 139. Doi: 10.1037/a0021314.
- Forman DR, O’Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Development and Psychopathology. 2007;19(2), 585–602. Doi: 10.1017/S0954579407070289
- Society for Research in Child Development. Report on healthy development: A summit on young children’s mental health, partnering development: A summit on young children’s mental health, partnering with communication scientists, collaborating across disciplines and leveraging impact to promote children’s mental health, 2009. Washington, DC: Author. 2009.
- Tomlinson M. Infant Mental Health in the Next Decade: A Call for Action. Infant Mental Health Journal. 2015; 36(6): 538-541. Doi: 10.1002/imhj.21537
- Leach LS, Poyser C, Cooklin AR, & Giallo R. Prevalence and course of anxiety disorders (and symptom levels) in men across the perinatal period: A systematic review. Journal Of Affective Disorders. 2016; 190: 675-686. doi:10.1016/j.jad.2015.09.063
- Kvalevaag AL, Ramchandani PG, Hove O, Assmus J, Eberhard-Gran M, Biringer E. Paternal mental health and socioemotional and behavioral development in their children. Pediatrics. 2013; 131(2), e463-9. Doi:10.1542/peds.2012-0804
- Nicholas M, Mares SP, Newman LK, Williams S, Powrie RM, & Karin T. Family matters: infants, toddlers and pre-schoolers of parents affected by mental illness. Medical Journal of Australia. 2012; 1: 14-17. doi:10.5694/mja11.11285
Niamh Doyle, Psychologist in Clinical Training, UCC/HSE. Correspondence to Niamh.Doyle5@hse.ie
Dr Marie Tierney, Clinical Psychologist, Cork.